NOTICES
DEPARTMENT OF PUBLIC WELFARE
Notice of Rule Change--Emergency Medical Condition
[28 Pa.B. 3623] The Department of Public Welfare (Department) announces that effective July 1, 1998, the Medical Assistance Program is:
1. revising its definition of ''emergency admission'';
2. adding new definitions of ''emergency medical condition'' and ''emergency medical care'';
3. deleting the definitions of ''emergency situation'' and ''emergency accident care''; and
4. deleting Appendix A of Chapter 1221, relating to Clinic and Emergency Room Services.
This Rule Change will be adopted by final rulemaking to 55 Pa. Code Chapter 1101, Section 1101.21; Chapter 1141, Sections 1141.2, 1141.59; Chapter 1150, Section 1150.2; and Chapter 1221, Sections 1221.2, 1221.59.
The Department, in consultation with the Pennsylvania Chapter of the American College of Emergency Physicians and the Hospital and Healthservices Association of Pennsylvania (HAP), is deleting the current definition of an ''emergency situation'' and replacing it with the definition of ''emergency medical condition''. The new definition is consistent with the definition included in the Balanced Budget Act of 1997.
The Department is also replacing the definition of ''emergency situation'' in Section 1141.2 with a definition of ''emergency medical care''; deleting the definition of ''emergency accident care'' and modifying the definition of ''emergency medical care'' in Section 1221.2; and revising the definition of ''emergency admission'' in Section 1150.2. In addition, the Department is revising the section on ''Non-emergency use of the emergency room'' under ''Noncompensable services'' in Sections 1141.59 and 1221.59.
Because of the unlimited numbers of medical conditions that could constitute an emergency situation, the list of symptoms and diagnoses in Appendix A to Chapter 1221 has become unintentionally restrictive. As a result, the Department is deleting Appendix A and all references to Appendix A throughout the regulations.
Failure to adopt these rule changes may result in recipients being denied emergency room services that are actual emergency situations.
This Rule Change has been reviewed by the Office of General Counsel and the Office of Attorney General.
This Rule Change is made under the Joint Committee on Documents Resolution 1998-1 (2), 28 Pa.B. 2629 (June 6, 1998), and will be in effect for 365 days pending adoption of final rulemaking by the Department.
A copy of this notice is available for review at local county assistance offices throughout the Commonwealth. Interested persons are invited to submit written comments to this notice within 30 days of this publication. Comments should be sent to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Suzanne Love, Room 515 Health and Welfare Building, Harrisburg, PA 17120.
Persons with a disability may use the AT&T Relay Service by calling 1 (800) 654-5984 (TDD users) or 1 (800) 654-5988 (Voice users). If you require another alternative, please contact Thomas Vracarich at (717) 783-2209.
FEATHER O. HOUSTOUN,
SecretaryPurpose
The purpose of this notice is to:
1. add a new definition of ''emergency medical condition'' and ''emergency medical care'';
2. revise the Medical Assistance definition of ''emergency admission'';
3. delete the definitions of ''emergency situation'' and ''emergency accident care''; and
4. delete Appendix A of 55 Pa. Code, Chapter 1221, relating to Clinic and Emergency Room Services.
Scope
This notice applies to all providers enrolled in the Medical Assistance Program, as well as both voluntary and mandatory managed care organizations under contract with the Department.
Background
On August 5, 1997, President Clinton signed the Balanced Budget Act of 1997 (BBA), which included a revised definition of ''emergency medical condition.'' To be consistent with BBA, the Department, in consultation with the Pennsylvania Chapter of the American College of Emergency Physicians and the Hospital and Healthservices Association of Pennsylvania, is deleting the current § 1101.21 definition of an ''emergency situation'' and replacing it with the definition of ''emergency medical condition.'' Effective July 1, 1998, § 1101.21, relating to definitions, will include the following definition of ''emergency medical condition'':
Emergency Medical Condition--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in--
(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part.
The Department is replacing the definition of ''emergency situation'' in § 1141.2 with a definition of ''emergency medical care''; deleting the definition of ''emergency accident care'' and modifying the definition of ''emergency medical care'' in § 1221.2; and revising the definition of ''emergency admission'' in § 1150.2. In addition, the Department is revising the section on ''Non-emergency use of the emergency room'' under ''Noncompensable services'' in §§ 1141.59 and 1221.59.
Because of the unlimited numbers of medical conditions that could constitute an emergency situation, the list of symptoms and diagnoses in Appendix A to Chapter 1221 has become unintentionally restrictive. As a result, the Department is deleting Appendix A and all references to Appendix A throughout the regulations.
Policy
Effective July 1, 1998, Chapter 1101--General Provisions, Chapter 1141--Physicians' Services, Chapter 1150--Medical Assistance Program Payment Policies, and Chapter 1221--Clinic and Emergency Room Services are revised as follows:
CHAPTER 1101. GENERAL PROVISIONS. * * * * * § 1101.21. Definitions.
Emergency Medical Condition--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in--
(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part.
[EMERGENCY SITUATION--A condition in which immediate medical care is necessary to prevent the death or serious impairment of health of the individual.]
* * * * *
CHAPTER 1141. PHYSICIANS' SERVICES. * * * * * § 1141.2. Definitions.
* * * * * Emergency Medical Care--Medical care rendered in response to an emergency medical condition as defined in § 1101.21 of this title.
[EMERGENCY SITUATION--A condition in which immediate medical care is necessary to prevent the death or serious impairment of health of the individual.]
* * * * * § 1141.59. Noncompensable services.
Payment will not be made for the following physician's services:
* * * * * (17) Non-emergency use of the emergency room. Services that do not meet the definition of emergency medical care of this chapter are not reimbursable unless the recipient declares that he/she does not have access to a primary care physician or an outpatient clinic to receive non-emergency care. The hospital emergency room staff and/or the emergency room physician must document in the patient's medical record the declaration of no access to primary care.
* * * * *
CHAPTER 1150. MEDICAL ASSISTANCE PROGRAM PAYMENT POLICIES. * * * * * § 1150.2. Definitions.
* * * * * Emergency Admission--An admission to a hospital for [a condition in which immediate medical care is necessary to prevent death, serious impairment or significant deterioration of the health of the patient] the purpose of rendering medical care in response to an emergency medical condition as defined in § 1101.21 of this title.
* * * * *
CHAPTER 1221. CLINIC AND EMERGENCY ROOM SERVICES. * * * * * § 1221.2. Definitions.
* * * * * [Emergency Accident Care--The initial examination and treatment performed in connection with and within 72 hours following an injury. Examples of emergency accident care include but is not limited to the following: removal of foreign body in the eye, treatment of abrasions, contusions, acute sprains or strains, nose bleeds--caused by trauma, insect bites or stings, choking on food, drink or foreign body, resuscitation of drowning or smoke inhalation victims, or treatment of concussion, or poisoning--chemical or drug.]
Emergency Medical Care--Medical care rendered in response [to the sudden onset of a medical condition requiring medical, nor surgical, intervention to sustain the life of the person or to prevent damage to the person's health and which the recipient secures immediately after the onset, or as soon thereafter as the care can be made available, but in no case later than 72 hours after the onset] an emergency medical condition as defined in § 1101.21 of this title. [In order to determine whether a medical emergency existed and, therefore, whether benefits for outpatient services in connection with the treatment of the condition are payable on an emergency basis, the following criteria shall be applied:
(i) Severe symptoms have to occur--The symptoms must be sufficiently severe to cause a person to seek immediate medical aid. Some symptoms or conditions indicating medical emergency care are listed in Appendix A.
(ii) Severe symptoms must occur suddenly and unexpectedly--Subacute symptoms of a chronic condition would not qualify as a medical emergency. However, chronic symptoms that suddenly become severe enough to require immediate intervention would qualify.]
* * * * * § 1221.59. Noncompensable services and items.
Payment will not be made to clinics or emergency rooms for the following services or items:
* * * * * (9) Non-emergency use of the emergency room. Services [to patients who do not exhibit symptoms or have a diagnosis that is listed in Appendix A] that do not meet the definition of emergency medical care of this chapter are not reimbursable unless the recipient declares that he/she does not have access to a primary care physician or an outpatient clinic to [treat nonemergency situations] receive nonemergency care. The hospital emergency room staff and/or the emergency room physician must document in the patient's medical record the declaration of no access to primary care.
* * * * *
[APPENDIX A. MEDICAL EMERGENCY CARE SYMPTOMS Allergy Reactions, Acute (Except Allergy Tests)
Appendicitis, Acute
Asthma, Acute
Breathing Difficulties or Shortness of Breath
Bronchitis, Severe
Bursitis, Severe Onset
Chest Pain, Severe
Choking
Colitis
Coma
Convulsions and/or Seizures
Cystitis
Dermatitis or Hives (Resulting From Internal
or Unknown Causes)Diabetic Coma
Diarrhea, Severe
Drug Reaction
Earache, Severe
Epistaxis (nosebleed)
Fainting
Fecal Impaction, Severe
Food Poisoning
Frost Bite
Gall Bladder, Acute Attack
Gastritis
Gastro-intestinal Conditions, Acute
Glaucoma, Severe
Headache, Severe
Heart Attack, Suspected
Hemorrhage
Hysteria
Insulin Shock (Overdose)
Kidney Stones
Maternity Complications, Such As Suspected
MiscarriagePain, Sudden or Severe Onset
Pleurisy
Pneumonitis
Poisoning (including overdose)
Pyelitis
Pyelonephritis (Shock)
Spasms, Cerebral or Cardiac
Spontaneous Pneumothorax
Stomach Pain, Severe
Strangulated Hernia
Stroke
Sunstroke
Swollen Ring Finger
Tachycardia
Thrombosis and/or Phlebitis
Unconsciousness
Urinary Retention, Acute
Vision Loss, Sudden Onset
Vomiting, Severe]
Fiscal Note: 14-NRC-73. (1) General Fund; (2) Implementing Year 1998-99 is $529,000; (3) 1st Succeeding Year 1999-00 is $529,000; 2nd Succeeding Year 2000-01 is $529,000; 3rd Succeeding Year 2001-02 is $529,000; 4th Succeeding Year 2002-03 is $529,000; 5th Succeeding Year 2003-04 is $529,000; (4) FY 1997-98 $662,740; FY 1996-97 $798,836; FY 1995-96 $792,293; (7) Medical Assistance--Outpatient; (8) recommends adoption. The increased cost for this rule change is included in the Department's 1998-99 budget.
[Pa.B. Doc. No. 98-1238. Filed for public inspection July 31, 1998, 9:00 a.m.]
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